Did you see campus nurse or other health care professional after getting injury? *

Yes

No

If yes, Physician's and/or Facility's Name

Physician/Facility Phone

What were you doing just before the incident occurred? Be specific:

What happened? Explain how the injury occurred including the cause(s) of the injury:

Any tools, equipment, material, or chemicals employee was using at time of injury:

Describe any previous injury to this body part:

Corrective action required to prevent a similar incident in the future:

Witness(es) Names:

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